Building Effective Cross-Border and Regional Cooperation in East Asia

"Building Effective Cross-Border and Regional Cooperation in East Asia," East Asian Regional Cooperation in the Fight Against HIV/AIDS, Tuberculosis, and Malaria; (Beijing Conference, 2006), Tokyo: Japan Center for International Exchange, 2006, pp. 30-37. 6 Building Effective Cross-Border and Regional Cooperation in East Asia The final two sessions of the conference focused specifically on models of crossborder and regional cooperation on communicable diseases. Six practitioners with firsthand experience operating joint initiatives described their work, and a wide-ranging discussion ensued about effective ways of building cooperation. The following is a summary of those discussions. In East Asia, it is becoming increasingly evident that greater cross-border and regional cooperation is direly needed. Economic development has accelerated the movement of people and goods, and the accompanying societal changes have often added to the complexity of preventing and treating HIV/AIDS, malaria, and tuberculosis. Unfortunately, there seems to be less of a foundation for regional cooperation in East Asia than in Europe or North America. Regional institutions are relatively underdeveloped, and there tends to be greater diversity from country to country in terms of culture, language, economic development, and political systems. Case Studies of Cross-Border and Regional Initiatives Despite the paucity of regional institutions, a number of cross-border initiatives have been undertaken in response to the spread of communicable diseases, and they have been bearing considerable fruit. Six exemplary cases were described by speakers at the conference, and each sheds light on the various challenges and benefits of cross-border responses. Copyright 2007, Japan Center for International Exchange

Building Effective Cooperation China-Vietnam Cross-Border Harm Reduction Program (Jie Chen, Guangxi Center for Disease Control and Prevention) A strain of HIV that originated in Southeast Asia has spread extensively among IDUs living on both sides of the China-Vietnam border in the Guangxi Autonomous Region in China and Lang Son Province in Vietnam, which are situated on a major heroin trafficking route. In response, in 2002, Chinese and Vietnamese authorities launched coordinated harm reduction programs that have included needle exchanges designed to take into account the mobility of IDUs across the border and on both sides of it. Japan-China Joint Research on Emerging and Re-emerging Infectious Diseases (Aikichi Iwamoto, University of Tokyo) With Japanese government funding, Japanese and Chinese researchers have started establishing joint China-Japan laboratories in China to focus on the spread of HIV/AIDS, avian influenza, hepatitis, and other infectious diseases. The Institute of Medical Sciences at the University of Tokyo has teamed up with the Institute of Biophysics and the Institute of Microbiology at the Chinese Academy of Sciences to establish two joint laboratories, and it is also engaged in a joint research program with the Harbin Veterinary Research Institute at the Chinese Academy of Agricultural Sciences. Funding for Cross-Border Health Issues in the Greater Mekong Subregion (Katherine Bond, Rockefeller Foundation) Over the last five years, the Rockefeller Foundation has provided more than US$7.2 million in interconnected grants addressing the cross-border spread of infectious diseases in the Greater Mekong Subregion, including Yunnan, China; Myanmar; Laos; Thailand; Cambodia; and Vietnam. Particular focus has been placed on migrants and refugees moving across borders and upland ethnic communities living in border areas that are especially vulnerable to disease. The cross-border health efforts draw on capacity from within the region to support poor, vulnerable communities and countries and to build institutions and human resources better able to respond to the challenges accompanying regional integration. 31

East Asian Regional Cooperation Cross-Border HIV/AIDS Cooperation in the Philippines (Eugenio Caccam) More than one-third of reported HIV/AIDS cases in the Philippines involve overseas foreign workers who have been employed in other countries in the region, some without proper legal documentation. The government of the Philippines has carried out pre-departure training sessions on HIV prevention for these workers and its embassies and a variety of NGOs have been providing prevention and treatment services to workers in their destination countries, although the capacity to do this in a robust manner has varied depending on the local environment of each host country. HIV/AIDS Program for the Second Mekong International Bridge Construction Project (Emi Inaoka, Japan Bank for International Cooperation, JBIC) JBIC, Japan s development aid agency, is funding the construction of the Second Mekong International Bridge between Thailand and Laos as part of an effort to create a 1,450 kilometer transportation corridor through the Greater Mekong Subregion. Because the construction project employs a large number of migrant workers in a border area, JBIC included the implementation of an HIV prevention program in the construction contracts. As a result, the Planned Parenthood Association of Thailand has been carrying out the Bridge of Hope project to raise awareness of sexually transmitted infections and provide testing services to construction workers and commercial sex workers in the area. SHARE (Services for the Health in Asian and African Regions) Supporting HIV/AIDS Treatment Access for Thai People Living in Japan (Sangnim Lee, SHARE) SHARE, a Japanese NGO that operates in Thailand and elsewhere around the world, has long worked to provide information on HIV/AIDS prevention and improve medical access for non-japanese nationals residing in Japan. Nearly one-fourth of all reported AIDS cases in Japan are among non-japanese nationals, many of whom cannot obtain medical insurance due to their undocumented status and who face the risk of being deported 32

Building Effective Cooperation to their home countries, where access to ARV treatment may be highly limited. Taking advantage of its experience in Thailand, SHARE launched a special program in 2004 to help provide access to ARV treatment for Thai people diagnosed with AIDS after their return to Thailand from Japan. Rationales for Cross-Border and Regional Cooperation These cross-border and regional efforts were launched for a variety of reasons. Participants noted that by building personal networks, cross-border collaboration facilitates the sharing of information and knowledge, in a sense creating an economy of scale in terms of expertise. Of course, information sharing in terms of disease surveillance is also critical so that neighboring countries can implement appropriate strategies to head off spreading epidemics. Other participants point out the importance of institutional learning, describing how regional cooperation encourages practitioners and policymakers in different countries to adopt effective approaches that they learn from one another. Meanwhile, another stressed the capacity of bilateral and multilateral cooperation to deepen the political commitment of each of the participating countries to respond to communicable diseases. The bottom line, however, is that conventional responses that stop at a county s borders cannot adequately cope with the spread of communicable diseases. Conference participants cited a number of serious shortcomings of unilateral and country-based responses as rationales for their efforts to build cross-border and regional cooperation. Some of the major ones included the following: 1) There are sizeable populations that fall through the cracks with conventional national responses. Migrant workers and other legal and illegal immigrants are often not covered or only partially covered by national disease surveillance, prevention, and treatment systems. As Sangnim Lee explained in outlining the activities of SHARE, undocumented Thai migrants in Japan often avoid seeking testing and treatment for HIV/AIDS until the illness has reached its final stages due to fears of forcible repatriation and their inability to obtain public health insurance to cover the formidable costs of treatment. Moreover, these hidden populations tend to include the very people who are at the greatest risk of infection commercial sex workers, young laborers who are far from their families and thus have a greater propensity 33

East Asian Regional Cooperation 34 to engage in risky activities, victims of trafficking, and those on the lower rungs of the socioeconomic ladder. 2) There are questions as to which entities have responsibility for protecting and caring for certain populations and even as to who has jurisdiction over them. Eugenio Caccam noted that, despite the efforts of the government of the Philippines to raise awareness about HIV/AIDS among workers departing for employment overseas, it is difficult to continue these efforts once they reach their destinations. Meanwhile, national and local governments in destination countries are often hesitant or unable to take on the burden of prevention and treatment for non-citizens. The issue of jurisdiction and responsibility becomes even more acute with refugees and stateless populations, such as the official and unofficial refugee communities in Thailand or among ethnic groups in Myanmar who oppose the central government. 3) Even when local and national authorities make a conscious effort, it is difficult for them to reach out to immigrant communities and build up the level of trust that is needed for effective prevention and treatment initiatives. These difficulties tend to be aggravated by linguistic and ethnic differences as well as by stigma and discrimination, and they are even greater for a variety of political and logistical reasons when dealing with immigrants who are undocumented or engaged in illegal activities. 4) Border areas, which are often remote and impoverished, pose a particular challenge in East Asia. This is especially true where minority ethnic groups straddle the border and their socioeconomic conditions and cross-border networks make them more vulnerable to disease and more likely to have frequent interactions across the border. Malaria remains endemic in a number of border areas in Southeast Asia, particularly in remote regions that are home to ethnic minorities, and it spreads without regard for the location of borders. Meanwhile, HIV/AIDS can be a pressing problem where the commercial sex industry and the drug trade draw people back and forth across borders. It is not just prevention initiatives that are likely to be fruitless when implemented only on one side of the border, but also other efforts. For example, one participant noted that people living in many border areas often cross into neighboring countries in order to obtain treatment, placing a greater burden on the country with the stronger health system.

Building Effective Cooperation 5) It is particularly difficult to ensure the continuity of prevention and treatment programs for mobile populations that cross borders. Chinese and Vietnamese authorities began cooperating because they realized that HIV/AIDS prevention initiatives had a limited impact when IDUs had ready access to clean needles in one country but would share needles whenever they crossed the border. Meanwhile, it is counterproductive to start people who have been diagnosed with HIV/AIDS on ARV treatment if they will not have access to these drugs when they cross borders for work, to return home, or for other reasons. Building Effective Cooperation While clearly needed, cross-border and regional initiatives tend, by their nature, to be more difficult to launch and implement than conventional responses. In addition to linguistic, cultural, and political barriers, these efforts are often hampered by a lack of personal and institutional networks, differing priorities, a lack of mutual understanding, and geopolitics. There is also significant diversity in the nature of communicable diseases around the region. In light of these challenges, participants recommended several steps that are key to the efficacy of cross-border and regional responses. The linguistic and cultural differences within the region are one of the greatest barriers to cross-border initiatives, so one element that needs to be stressed is information sharing between counterparts. Since they typically do not share the same social networks, policymakers and practitioners in different countries who are formulating and implementing joint responses tend to have lower levels of familiarity with one another and further to go in building a foundation of trust. This means it is important to make greater efforts to increase transparency at all stages of the cooperative process and to cultivate a sense of shared ownership. In some instances this may necessitate operating in three, four, or more different languages and local dialects. This may also require special efforts to promote exchanges of leaders from different sectors of society or to build personal networks. For example, Jie Chen of the Guangxi Center for Disease Control and Prevention noted that China-Vietnam harm reduction programs have been aided by an active exchange of public health officials from both countries. Participants with extensive experience implementing cross-border and regional responses also counseled that it is important to build flexibility 35

East Asian Regional Cooperation into programs so that they can incorporate approaches that are appropriate given the local culture. For example, the participation of peer educators has been increasingly instrumental on the China side of the China-Vietnam needle exchanges because the stigma connected to drug use and HIV/AIDS is so strong in China. Financial inducements are also being used, and 0.1 yuan (roughly US$0.01) was paid per needle collected. Meanwhile, on the Vietnam side, where vouchers remain relatively popular, program organizers have relied more on a system of vouchers to allow users to obtain clean needles from different distribution points. One participant also mentioned that the need to take flexible and sometimes differing approaches as part of the same initiative underscores the importance of involving private foundations and other private funders on the donor side, since the accountability requirements of governments and international agencies often make them more rigid in terms of what they can support. The movement of people touches many different aspects of government and society, so participants also stressed that it is critical to elicit broad multisectoral and multi-agency cooperation in order to carry out effective cross-border responses. For example, the implementation of an HIV/AIDS prevention program during the construction of the Second Mekong International Bridge demonstrates that bilateral and multilateral cooperation on communicable diseases works best when it involves not just health ministries and foreign ministries but also development banks, construction ministries, and labor ministries. In this case, a task force was formed to bring together representatives from the transportation sector, the health sector, NGOs, and private businesses, and this group met monthly to coordinate and monitor the program. The participation and support of private businesses, primarily construction companies and other contractors, also turned out to be indispensable, because they stood on the front lines as the employers of the construction workers who were at risk of infection and they were the institutions with the best access to these workers. One particular element of multisectoral participation on which a wide range of participants placed special emphasis is the need to involve and empower NGOs, which usually have the expertise and flexibility to respond more adeptly to evolving circumstances than other actors. Government officials tend to find it very difficult to reach out to vulnerable populations who are often the targets of cross-border initiatives including commercial sex workers, IDUs, MSM, and immigrant communities sometimes for linguistic and cultural reasons, sometimes because they cannot deal openly 36

Building Effective Cooperation with them for political reasons, and often because it is difficult for them to build up the requisite level of trust. In these cases, NGOs, including those staffed by people who are considered peers of these vulnerable populations, play an integral role as a bridge between the government and vulnerable groups, in representing and voicing these groups concerns, and in providing the firsthand knowledge and flexibility to devise and implement effective prevention and treatment schemes. A wide range of participants from various countries added a caveat, however, stressing that NGOs in the region direly need a stronger financial base and a more amenable legal environment if they are to live up to their full potential. Finally, there is a need to build up institutional frameworks to implement cross-border and regional interventions. As one participant noted, there is no shortage of political commitment and agreements on cross-border cooperation, but people simply do not know who to deal with on the other side of the border. The relative lack of regional organizations and arrangements means that there are few established patterns of cooperation to ease the difficulties of dealing with the complex issues that arise in any collaboration. Institutional and personal networks often have to be built from the ground up in launching cooperative initiatives, and funding for multi-country initiatives often has to be done through individual, country-based institutions rather than in a more comprehensive manner. Some participants identified ASEAN as a potentially important player in building regional cooperation, particularly because its mandate already covers communicable diseases, and others noted that the East Asia Summit and other East Asia community-building efforts might be helpful in creating mechanisms for joint action. There was a general consensus, however, that much more work is needed in this area. 37